﻿<?xml version="1.0" encoding="utf-8"?>
<!--148 Report of Injury, Illness or Incident-->
<TransactionSpecification TransactionSetIdentifierCode="148" xmlns="http://tempuri.org/X12ParserSpecification.xsd">
  <Segment SegmentId="BGN" />
  <Segment SegmentId="CUR" />
  <Segment SegmentId="QTY" />
  <Segment SegmentId="REF" />
  <Segment SegmentId="GRI" Trailer="true"/>
  <Loop LoopId="LX">
    <Name>Assigned Number</Name>
    <StartingSegment SegmentId="LX" />
    <Segment SegmentId="QTY" />
  </Loop>
  <Loop LoopId="NM1">
    <Name>Individual or Organizational Name</Name>
    <StartingSegment SegmentId="NM1" />
    <Segment SegmentId="N2" />
    <Segment SegmentId="N3" />
    <Segment SegmentId="N4" />
    <Segment SegmentId="PER" />
    <Segment SegmentId="ACT" />
    <Segment SegmentId="DTP" />
    <Segment SegmentId="DMG" />
    <Segment SegmentId="REF" />
    <Segment SegmentId="QTY" />
    <Segment SegmentId="CRC" />
  </Loop>
  <!-- LevelCode left empty since multiple allowed values -->
  <HierarchicalLoop LoopId="HL">
    <!-- HL identifies the appropriate hierarchical level: Reporting Agency (RA), 
        Primary Administrator (PA), Secondary Administrator (SA), Contractholder (CH), 
        Contractholder Branch Office (CB), Claimant (CL), Cause of Injury (CI), Source 
        of Injury (SI), Body Part (BP), Nature of Injury (NI), and Payment Detail (PY). 
        All levels are optional.-->
    <Name/>
    <Segment SegmentId="CRI" />
    <Segment SegmentId="ACT" />
    <Segment SegmentId="DTP" />
    <Segment SegmentId="CUR" />
    <Segment SegmentId="AMT" />
    <Segment SegmentId="FC" />
    <Segment SegmentId="REF" />
    <Segment SegmentId="DMG" />
    <Segment SegmentId="QTY" />
    <Segment SegmentId="CRC" />
    <Segment SegmentId="EMT" />
    <Segment SegmentId="VEH" />
    <Loop LoopId="NM1">
      <Name>Individual or Organizational Name</Name>
      <StartingSegment SegmentId="NM1" />
      <Segment SegmentId="N2" />
      <Segment SegmentId="N3" />
      <Segment SegmentId="N4" />
      <Segment SegmentId="PER" />
      <Segment SegmentId="ACT" />
      <Segment SegmentId="DTP" />
      <Segment SegmentId="DMG" />
      <Segment SegmentId="REF" />
      <Segment SegmentId="QTY" />
      <Segment SegmentId="CRC" />
    </Loop>
    <Loop LoopId="ESI">
      <Name>Employment Status Information</Name>
      <StartingSegment SegmentId="ESI" />
      <Segment SegmentId="EMT"/>
      <Segment SegmentId="TPB"/>
      <Segment SegmentId="DTP" />
      <Segment SegmentId="REF" />
      <Segment SegmentId="QTY" />
      <Segment SegmentId="NM1" />
      <Segment SegmentId="PER" />
      <Segment SegmentId="CRC" />
      <!-- From 4010 -->
      <Loop LoopId="AIN">
        <Name>Income</Name>
        <StartingSegment SegmentId="AIN" />
        <Segment SegmentId="CUR" />
        <Segment SegmentId="TXI" />
        <Segment SegmentId="WS" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="QTY" />
      </Loop>
      <!-- From Current -->
      <Loop LoopId="LX">
        <Name/>
        <StartingSegment SegmentId="LX"/>
        <Segment SegmentId="AIN"/>
        <Segment SegmentId="CUR" />
        <Segment SegmentId="TXI" />
        <Segment SegmentId="WS" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="QTY" />
        <Segment SegmentId="REF" />
      </Loop>
    </Loop>
    <Loop LoopId="LN">
      <Name>Loan Information</Name>
      <StartingSegment SegmentId="LN" />
      <Segment SegmentId="REF" />
      <Loop LoopId="VEH">
        <Name>Vehicle Information</Name>
        <StartingSegment SegmentId="VEH" />
        <Segment SegmentId="N4" />
        <Segment SegmentId="PID" />
      </Loop>
      <Loop LoopId="AMT">
        <Name>Monetary Amount</Name>
        <StartingSegment SegmentId="AMT" />
        <Segment SegmentId="PCT" />
        <Segment SegmentId="DTP" />
      </Loop>
      <Loop LoopId="NM1">
        <Name>Individual or Organizational Name</Name>
        <StartingSegment SegmentId="NM1" />
        <Segment SegmentId="DMG" />
        <Segment SegmentId="N3" />
        <Segment SegmentId="N4" />
        <Segment SegmentId="PER" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="REF" />
      </Loop>
    </Loop>
    <!-- From 4010 -->
    <Loop LoopId="III">
      <Name>Information</Name>
      <StartingSegment SegmentId="III" />
      <Segment SegmentId="IMP" />
      <Segment SegmentId="DTP" />
      <Segment SegmentId="CRC" />
      <Loop LoopId="LM">
        <Name>Code Source Information</Name>
        <StartingSegment SegmentId="LM" />
        <Segment SegmentId="LQ" />
      </Loop>
      <Loop LoopId="NM1">
        <Name>Individual or Organizational Name</Name>
        <StartingSegment SegmentId="NM1" />
        <Segment SegmentId="N2" />
        <Segment SegmentId="N3" />
        <Segment SegmentId="N4" />
        <Segment SegmentId="PER" />
        <Segment SegmentId="ACT" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="DMG" />
        <Segment SegmentId="REF" />
      </Loop>
      <Loop LoopId="AD1">
        <Name>Adjustment Amount</Name>
        <StartingSegment SegmentId="AD1" />
        <Segment SegmentId="CUR" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="QTY" />
        <Segment SegmentId="REL" />
        <Loop LoopId="NM1">
          <Name>Individual or Organizational Name</Name>
          <StartingSegment SegmentId="NM1" />
          <Segment SegmentId="N2" />
          <Segment SegmentId="N3" />
          <Segment SegmentId="N4" />
          <Segment SegmentId="PER" />
          <Segment SegmentId="ACT" />
          <Segment SegmentId="DTP" />
          <Segment SegmentId="DMG" />
          <Segment SegmentId="REF" />
        </Loop>
      </Loop>
    </Loop>
    <!-- From Current -->
    <Loop LoopId="LS">
      <Name></Name>
      <StartingSegment SegmentId="LS"/>
      <Segment SegmentId="LE" Trailer="true"/>
      <Loop LoopId="III">
        <Name>Information</Name>
        <StartingSegment SegmentId="III" />
        <Segment SegmentId="IMP" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="CRC" />
        <Segment SegmentId="QTY" />
        <Segment SegmentId="REF" />
        <Loop LoopId="LM">
          <Name>Code Source Information</Name>
          <StartingSegment SegmentId="LM" />
          <Segment SegmentId="LQ" />
        </Loop>
        <Loop LoopId="NM1">
          <Name>Individual or Organizational Name</Name>
          <StartingSegment SegmentId="NM1" />
          <Segment SegmentId="N2" />
          <Segment SegmentId="N3" />
          <Segment SegmentId="N4" />
          <Segment SegmentId="PER" />
          <Segment SegmentId="ACT" />
          <Segment SegmentId="DTP" />
          <Segment SegmentId="DMG" />
          <Segment SegmentId="REF" />
          <Segment SegmentId="CRC" />
        </Loop>
      </Loop>
    </Loop>
    <Loop LoopId="CFI">
      <Name/>
      <StartingSegment SegmentId="CFI"/>
      <Segment SegmentId="CUR"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="QTY"/>
      <Segment SegmentId="REL"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="CRC"/>
      <Loop LoopId="AD1">
        <Name>Adjustment Amount</Name>
        <StartingSegment SegmentId="AD1" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="REL" />
      </Loop>
      <Loop LoopId="NM1">
        <Name>Individual or Organizational Name</Name>
        <StartingSegment SegmentId="NM1" />
        <Segment SegmentId="N2" />
        <Segment SegmentId="N3" />
        <Segment SegmentId="N4" />
        <Segment SegmentId="PER" />
        <Segment SegmentId="ACT" />
        <Segment SegmentId="DTP" />
        <Segment SegmentId="DMG" />
        <Segment SegmentId="REF" />
      </Loop>
    </Loop>
  </HierarchicalLoop>
</TransactionSpecification>